You can help your homebound patients

The chronically ill and frail elderly are often unable to get to your office.
If you cannot make house calls, you can still direct good care their way.

Mrs. D, age 85, has diabetes mellitus and osteoarthritis of the knees and hips. Because she has fallen several times and is afraid of walking outside, she is missing most of her appointments at your office. Her daughter does all her shopping and laundry but works full-time and is having trouble managing her mother’s care. Mrs. D has Medicare coverage, and her daughter is in the process of helping her apply for Medicaid.

This case illustrates a common problem encountered by many primary-care clinicians: providing care for the housebound. This article will describe how a clinician can use home care services to assist such patients, improve their quality of life, and alleviate their caregivers’ stress. We will describe who qualifies for skilled home care, how to obtain it for your patients, and how to get reimbursed for coordinating the various services. We will also address how providers themselves can carry out home visits and get reimbursed for doing so.

Home care is defined as any diagnostic, therapeutic, or social support service provided in the home by a physician, nurse practitioner, or physician assistant. It also includes professional services of social workers, dentists, podiatrists, psychologists, dietitians, optometrists, and pharmacists. More commonly, home care involves the services of nurses, physical therapists, occupational therapists, and speech therapists.

Diagnostic services, such as labs, x-ray, and ultrasound, ECG and Holter monitoring, can be provided in the home as well. Supportive services provided by home health aides (HHAs), home attendants, housekeepers, and meal-delivery companies are also common. Equipment is another important aspect of home care (e.g., infusion therapy, ventilators, hospital beds, wheelchairs, lifts, and commodes). Home care even encompasses hospice care and telemedicine.

Why provide home care?

Providing care in the home can give you valuable insight into patients’ lives and illnesses. A clinician in the home can also provide more patient-centered care. Home care is not charity care—you can bill for home visits and the coordination of home-care services.

Historically, the majority of medical and nursing care had been provided in the home. It was not until the era of the First and Second World Wars that medical care became more advanced (with the introduction of IV fluids, antibiotics, and surgical procedures) and shifted to the hospital setting. In 1965, home care received an enormous boost with the passage of Medicare, which covered care for elderly patients sent home from the hospital. This coverage was extended in the 1980s to include long-term home care even without a recent hospitalization. In the early 1990s, Medicare reimbursement for home visits increased, stimulating a resurgence of house calls by physicians, NPs, and PAs. By 1999, there were 2 million home visits in this country, a 35% increase from just five years before.

Who qualifies for home care by a certified home-care agency?

A patient needs to meet three criteria:
1. The patient must be temporarily or permanently homebound. Medicare requires a patient to have a “normal inability to leave the home” and that “leaving home requires a considerable and taxing effort by the individual.” It says that a patient needs to leave the home “infrequently or of relatively short duration” and/or need the assistance of another person or an assistive device (wheelchair, walker, cane, etc). Going to medical appointments, dialysis, adult day-health programs, and religious services do not count in the “infrequently” definition. It is also generally acceptable to go to a family gathering or hairdresser once a week.
2. The patient must have a need for skilled care. For nursing referrals, such needs include monitoring vital signs, such as BP, pulse, and temperature; monitoring drains and dressing wounds; titrating medication for symptom management; and patient and family education about such matters as diabetes, heart failure, tube feeding, and ostomy care. For physical therapy, common referrals include gait and balance training, home safety assessment, family/caregiver education for exercises to prevent or manage contractures, and evaluation for and instruction regarding assist devices. A referral can be made directly for a registered nurse, physical therapist, or speech therapist; once those services have been started, occupational therapy, lab testing, social work, nutrition counseling, home health aides, and others can be added.
3. The services must be paid for by insurance. As long as the first two criteria are met, Medicare will pay for home care (the payment is via Medicare part A); the patient does not pay any additional costs or co-payments. Home care agencies get paid for 60-day periods based on the patient’s comorbidities and need for skilled care. Private insurance and HMOs usually require prior authorization for a limited number of visits; the patient may incur some associated costs.

How do you order home care services by a certified agency?

Agencies usually want to make it easy for the practitioner to make these referrals; however, for a Medicare patient, the referral can officially be made only by a physician. An NP or PA who makes the referral needs to indicate the collaborating physician’s name but should also indicate that the NP or PA is the person to contact regarding the patient.

In the referral, be specific about when to contact the provider (e.g., whether you want to be paged about every elevated BP reading or simply updated at the end of the week). On initial contact with the nurse or therapist from the home care agency, obtain contact information. Clarify the goals of the treatment plan. Ask for the nurse or therapist’s input and encourage open communication, which includes a mechanism to notify the nurse when the clinician makes changes in medication or the plan of care.

What is “nonskilled” home care?

Nonskilled home care includes assistance from any aide, such as a home attendant, private aide, or HHA. An HHA is a Medicare-funded, short-duration assistant (usually only a few hours a day) who is supervised and selected by the home health agency. Therefore, the patient must have a concurrent skilled need.

A home attendant, on the other hand, is a Medicaid-funded, chronic-duration worker who can stay up to 24 hours a day. These aides provide support for the activities of daily living. While they cannot administer medications, tube-feed, or provide wound care, they can supervise a patient in these activities. HHA services will stop when the patient no longer has a skilled home care need; HHA services can continue even without a concurrent skilled need.

How do you obtain home equipment for your patients?

Medical equipment is either durable or nondurable. Durable equipment includes hospital beds, wheelchairs, walkers, commodes, and lifts. These are 80% paid for by Medicare (part B), and private insurance will cover part of the remainder. Nondurable medical equipment includes diapers, wipes, gloves, and dressing materials, and is generally not paid for by Medicare (it is covered by Medicaid in some states).

Most orders can be placed via telephone followed by signing papers received by mail or fax. The vendor will need the patient’s diagnosis and insurance information; the few items that need a written prescription can initially be faxed to the vendor. For some items, the clinician will need to complete a standard Medicare Certificate of Medical Necessity, which includes a series of yes/no questions and may require additional documentation (e.g., the most recent visit note). Just like any medical form, sign and date it the day you complete it (not the original day of the request). Never sign for equipment you do not believe is medically necessary, and never accept an equipment company’s oxygen saturation reading, even when they offer to do this for you.

How do practitioners get reimbursed?

There are two opportunities for primary-care clinicians to be reimbursed for home care: (1) for providing a home visit as part of your practice, and (2) for coordinating care by the home care agencies.

Click to Enlarge

If you conduct home visits, it is very important to bill for them. There are separate codes for visits to the home and to an assisted-living facility (domiciliary codes) (Table 1). In addition, there are many resources that can provide assistance on home visits. Excellent examples include the American Academy of Home Care Physicians (www.aahcp.org) or local geriatrics and family medicine training programs. When you do an occasional home visit, the patient does not need to be homebound; instead, you document the need for the home visit such as “patient with multiple falls at home,” “medication review,” “patient never brings in medications,” etc. However, if all the encounters with the patient in the home are for primary care, then he or she should also meet the homebound criteria.

Coordination includes two separate billable activities. The first is home care certification. This was introduced in 2000 to encourage participation. When you order home care, you will receive a certification form (HCFA-485). Physicians can review, sign, and return the form to the agency—document this in the chart, and submit a bill to Medicare. The code is G0180 for a new plan of care and G0179 for a recertification (Table 2). This form can be submitted only by a physician who has seen the patient within six months. For NPs and PAs, the collaborating or supervising physician must be the one to bill for these services. The services are billed under Medicare part B. The patient will receive a bill for 20% of the charge if he has no other insurance.

Click to Enlarge

Oversight is the second part of coordination of care. Medicare pays for oversight of patients receiving acute skilled home care or hospice care. If any practitioner spends more than 30 minutes a month in billable activities, these must be documented. Among other things, such activities include speaking with the nurse, physical therapist, and physician consultants and reviewing labs not associated with a visit. Such activities do not include speaking with the patient or family.

The agency number and address must be included in the billing. The code is G0181 for home health agency and G0182 for a hospice agency. These are billed under Medicare part B (again, the patient will receive a bill for 20% of the charge). For collaborative practices in which providers share the responsibility for patients, the time cannot be combined between providers. Only one provider can bill and must have spent 30 minutes coordinating the care of the patient.

Case study, continued

Returning to the case of Mrs. D, a referral to a skilled home care agency would be appropriate. Physical therapy, both for home safety evaluation and to assess and improve Mrs. D’s gait and balance, would be an adequate primary referral. Home nursing visits for glucose monitoring/teaching and titration of pain medication (if her osteoarthritis requires it) might also be appropriate.

Once the skilled home care agency is involved, its social worker can help her daughter with the Medicaid application and managing the stresses of Mrs. D’s care. She might need the assistance of a home health aide, but these services probably would not be for a long duration or many hours per week. She is more likely to be able to get home attendant services once she obtains Medicaid. Mrs. D would benefit from a home visit from a physician, NP, or PA. This visit could focus on her risk factors for falls at home. Continued home visits may or may not be necessary depending on whether the patient can get outside.

If the provider visits the home, she should bill the home visit codes and document the reason. (The physician can also bill for the certification and subsequent recertifications of home care.

If the primary-care provider is an NP or PA, then the collaborating physician can bill for these if he or she has seen the patient in the last six months.) Lastly, if the provider spends more than 30 minutes in a given month coordinating care, she can bill for care plan oversight.

Dr. DeCherrie is assistant professor in the Department of Geriatrics and Dr. Soriano is assistant professor in the Department of Medicine, both at the Mount Sinai Medical School in New York City. Both are also affiliated with the school’s Visiting Doctors Program.

ClinicalAdvisor.com is for nurse practitioners and physician assistants, offering the latest information on diagnosing, treating, managing, and preventing medical conditions typically seen in the office-based primary-care setting.

Find all of the news and departments you love from the print issue archived for easy online access, along with special Web-only content.